Medical Respite Complex Care Coordinator (LSW)

PHMC is proud to be a leader in public health. Our Mission is to be the premier regional provider of integrated community-based healthcare by combining evidence-based clinical practices outstanding patient service innovative care partnerships and team-driven excellence within a healthy fiscal environment.

JOB DESCRIPTION :

The Medical Respite Complex Care Coordinator provides direct social services and care coordination to patients across PHMC Health Medical Respite locations. The Medical Respite Complex Care Coordinator will play a central role in leading patient intake connecting patients to public benefits participating in care planning coordinating patient discharges and supporting safe transitions of care.

The Medical Respite Complex Care Coordinator works intensively with diverse and underserved patient populations staying at the PHMC Health medical respite and collaborates with PHMC Health Center staff to improve patient health outcomes. The Complex Care Coordinator also serves as a primary point of contact for external referral sources medical offices and family members ensuring clear communication and continuity between hospital systems the PHMC Respite Programs and community placements. The Medical Respite Complex Care Coordinator actively engages as a member of the PHMC Health social service team and participates in all PHMC Health social service training sessions.

The Medical Respite Complex Care Coordinator must possess at minimum a License in Social Work (LSW) and will receive clinical supervision from an LCSW from within the Health Network when needed.

Responsibilities :

• Direct Patient Care & Case Management
• Conduct multidisciplinary intakes and assessments within 48 business hours of admission to identify barriers to recovery and discharge readiness.
• Develop individualized care plans with clear time-limited goals aligned with medical behavioral and social priorities.
• Provide brief counseling and support focused on motivation problem-solving and resource navigation.
• Coordinate daily with nursing and medical respite staff regarding changes in patient needs barriers or discharge timelines.
• Participate in telehealth appointments as needed to support communication and care continuity.
• Provide same-day assistance with transportation coordination for discharges follow-ups or appointments.
• Field and respond to calls from family members care managers or medical providers related to patient status and social needs.

Discharge Planning & Coordination

Resource Navigation & Benefits Access

Interdisciplinary Collaboration

Documentation and Reporting

Skills :

Experience :

Education Requirement :

Required Experience :

IC

Key Skills

DME,Medical Documentation,Typing,Developmental Disabilities Experience,Computer Skills,Data Collection,ICD-10,Medical Management,Medical office experience,Vital Signs Experience,Pediatrics Experience,Medical Terminology

Employment Type : Full-Time

Experience : years

Vacancy : 1